State-of-the-Art Paper
Valvular Aortic Stenosis: Disease Severity and Timing of Intervention

https://doi.org/10.1016/j.jacc.2006.03.002Get rights and content
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Standard echocardiographic evaluation of aortic stenosis (AS) severity includes measurement of aortic velocity, mean transaortic pressure gradient, and continuity equation valve area. Although these measures are adequate for decision making in most patients, there is no single value that defines severe stenosis. Aortic stenosis affects not just the valve, but the entire vascular system, including the left ventricle (LV) and systemic vasculature. More sophisticated measures of disease severity might explain the apparent overlap in hemodynamic severity between symptomatic and asymptomatic patients and might better predict the optimal timing of valve replacement. There have been several approaches to evaluation of stenosis severity based on valve hemodynamics, the ventricular response to increased afterload, ventricular-vascular coupling, or the systemic functional consequences of valve obstruction, such as exercise testing and serum brain natriuretic peptide levels. Aortic valve replacement is indicated when symptoms due to severe AS are present. In most asymptomatic patients, the risk of surgery is greater than the risk of watchful waiting so that management includes patient education, periodic echocardiography, and cardiac risk factor modification. Many adults with AS have comorbid conditions that affect both the diagnosis and management of the valve disease, including aortic regurgitation, aortic root dilation, hypertension, coronary artery disease, LV dysfunction, and atrial fibrillation. Comorbid conditions should be evaluated and treated based on established guidelines, although awareness of the potential effects of therapy in the presence of valve obstruction is needed.

Abbreviations and Acronyms

AR
aortic regurgitation
AS
aortic stenosis
AVA
aortic valve area
AVR
aortic valve replacement
CSA
cross-sectional area
LV
left ventricle/ventricular
LVOT
left ventricular outflow tract
VTI
velocity-time integral
Zva
valvulo-ventricular impedance
ΔP
pressure gradient

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